For management purpose preeclampsia is divided into two categories i.e., mild preeclampsia and severe preeclampsia.

Severe and mild preeclampsia are managed differently.

But this categorization does not matter in this case because of the gestational age of the patient.

– “The gestational age of the patient is 37 weeks and any case of preeclampsia 37 weeks gestational age is delivered immediately irrespective of the severity of the preeclampsia”.

The main concern here is the mode of delivery

-The patient presents with unfavourable cervix and a history of previous LS.C.S.

– The best mode of delivery in such a patient with mild preeclampsia is performing an L.S.C.S.

Q. 2

Indications for caesarean section in pregnancy are all except â€‘

A

Eisenmenger syndrome

B

Aortic stenosis

C

M.R.

D

Aortic regurgitaion

Q. 2

Indications for caesarean section in pregnancy are all except â€‘

A

Eisenmenger syndrome

B

Aortic stenosis

C

M.R.

D

Aortic regurgitaion

Ans.

A

Explanation:

Eisenmenger syndrome Eisenmenger’s syndrome

Maternal mortality rate in Eisenmenger’s syndrome is 30-40%

– Because of high maternal mortality rate patient should he counselled to avoid pregnancy and if pregnant consider termination of pregnancy.

– Because of high maternal mortality rate abortion is the t/t of choice.

If any pregnancy continues upto term in Eisenmenger’s syndrome, there is no evidence to support the choice of either vaginal or cesarean delivery.

Maternal mortality rate with normal delivery is 34% and with cesarean section is 75%.

Mitral regurgitation

Mitral regurgitation is usually tolerated well during pregnancy. The marked decrease in systemic vascular resistance that occurs during pregnancy alleviates the abnormal physiologic stress imposed by this lesion. Rarely, reactive pulmonary hypertension and severe right heart failure may ensue.

There are no specific recommendations for the management of mitral regurgitation during labour and delivery. Prior to labour, symptoms may be managed with diuretics and vasodilators. During labour, regional anaesthesia is usually well tolerated. However, in complicated NYHA class 3-4 cases, cesarean section and general anaesthesia may be required.

Aortic stenosis

In general the symptoms of aortic stenosis are masked by progressive left ventricular hypertrophy and are thus easily missed. Overall, patients who were asymptomatic prior to pregnancy usually tolerate pregnancy relatively uneventfully.

Echocardiographic determination of valve area is the best guide to severity of aortic stenosis. The hyperdynamic circulation of pregnancy frequently leads to overestimation of the degree of stenosis.

These patients tolerate tachycardia, hypovolaemia and systemic vasodilatation poorly, since coronary perfusion is critically dependent upon maintaining aortic diastolic pressure. General anaesthesia and caesarean section, with the aid of invasive haemodynamic monitoring, appears to be the safest means of successful delivery.

Aggressive maintenance of systemic blood pressure with vasopressors (e.g. phenylephrine), is paramount to the avoidance of severe hypotension, acute left ventricular failure and cardiac arrest.

Spinal anaesthesia is generally contraindicated in these patients. There are reports of the successful management of vaginal delivery under carefully introduced and limited epidural analgesia, but this should be restricted to very experienced hands.

Aortic regurgitation

Aortic regurgitation also reduces both cardiac output and coronary blood flow. Like M.R. it is well tolerated in pregnancy. The preferred mode of delivery in A.R. vaginal delivery unless obstetrical indications for cesarean exist. The crux is

i) Both Aortic regurgitation and mitral regurgitation are well tolerated during pregnancy. Vaginal delivery is the preferred mode of termination of pregnancy unless there are obstetrical indications for cesarean section.

ii) Aortic stenosis carries more risk than the above two disorders and the preferred mode of delivery is cesarean section.

A primigravida at 37 week of gestation reported to labour room with central placenta previa with heavy bleeding per vaginum. The fetal heart rate was normal at the time of examination. Which of the following is the best management option for her?

A

Caesarean section

B

Expectant management

C

Induction and vaginal delivery

D

Induction and forceps delivery

Q. 7

A primigravida at 37 week of gestation reported to labour room with central placenta previa with heavy bleeding per vaginum. The fetal heart rate was normal at the time of examination. Which of the following is the best management option for her?

A

Caesarean section

B

Expectant management

C

Induction and vaginal delivery

D

Induction and forceps delivery

Ans.

A

Explanation:

Since this patient in labour is having central type placenta previa with heavy vaginal bleeding, the most appropriate step in management is to conduct caesarean section.

Vaginal delivery usually is reserved for patients with a marginal implantation and a cephalic presentation. If vaginal delivery is elected, the membranes should be artificially ruptured prior to any attempt to stimulate labor (oxytocin given before amniotomy is likely will cause further bleeding).

In classical caesarean section more chances of rupture of uterus is in :

A

Upper uterine segment

B

Lower uterine segment

C

Utero cervical junction

D

Posterior uterine segment

Q. 10

In classical caesarean section more chances of rupture of uterus is in :

A

Upper uterine segment

B

Lower uterine segment

C

Utero cervical junction

D

Posterior uterine segment

Ans.

A

Explanation:

Upper uterine segment

Q. 11

Best management in Mento-posterior presentation:

A

Vaginal delivery

B

Forceps delivery

C

Manual rotation

D

Caesarean section

Q. 11

Best management in Mento-posterior presentation:

A

Vaginal delivery

B

Forceps delivery

C

Manual rotation

D

Caesarean section

Ans.

D

Explanation:

Caesarean section

Q. 12

Which of the following is an absolute indication for caesarean section in pregnancy associated with heart disease?

A

Pulmonary stenosis

B

Coarctation of aorta

C

Eisenmenger syndrome

D

Ebstein’s anomaly

Q. 12

Which of the following is an absolute indication for caesarean section in pregnancy associated with heart disease?

A

Pulmonary stenosis

B

Coarctation of aorta

C

Eisenmenger syndrome

D

Ebstein’s anomaly

Ans.

B

Explanation:

Coarctation of aorta

Q. 13

True about transient tachypnoea of new born is ‑

A

Air bronchogram seen

B

Common in preterm infants

C

Interlobar fissure effusion

D

Respiratory distress resolves in 6-10 days

Q. 13

True about transient tachypnoea of new born is ‑

A

Air bronchogram seen

B

Common in preterm infants

C

Interlobar fissure effusion

D

Respiratory distress resolves in 6-10 days

Ans.

C

Explanation:

Ans. is ‘c‘ i.e., Interlobar fissure effusion

Q. 14

A 26 year old third_gravida mother delivered a male baby weighing 4-2 kg at 37 weeks of gestation through an emergency caesarean section, for obstructed labour. The child developed respiratory distress one hour after birth. He was kept nil per orally (NPO) and given intravenous fluids. He maintained oxygen saturation on room air. No antibiotics were given. Chest radiograph revealed fluid in interlobar fissure. Respiratory distress settled by 24 hours of life. What is the most likely diagnosis ?

A

Transient tachypnea of the newborn

B

Meconium aspiration syndrome

C

Persistent fetal circulation

D

Hyaline membrane disease

Q. 14

A 26 year old third_gravida mother delivered a male baby weighing 4-2 kg at 37 weeks of gestation through an emergency caesarean section, for obstructed labour. The child developed respiratory distress one hour after birth. He was kept nil per orally (NPO) and given intravenous fluids. He maintained oxygen saturation on room air. No antibiotics were given. Chest radiograph revealed fluid in interlobar fissure. Respiratory distress settled by 24 hours of life. What is the most likely diagnosis ?

A

Transient tachypnea of the newborn

B

Meconium aspiration syndrome

C

Persistent fetal circulation

D

Hyaline membrane disease

Ans.

A

Explanation:

Ans. is ‘a’ i.e., Transient tachypnea of newborn

o Respiratory distress, which resolves within 24 hours without any respiratory support and fluid in interlobar fissure on chest X-ray suggest the diagnosis of TTN.

Q. 15

A 21 year old lady with a history of hypersensitivity to neostigmine is posted for an elective caesarean section under general anesthesia. The best muscle relaxant of choice in this patient should be:

A

Pancuronium

B

Atracurium

C

Rocuronium

D

Vecuronium

Q. 15

A 21 year old lady with a history of hypersensitivity to neostigmine is posted for an elective caesarean section under general anesthesia. The best muscle relaxant of choice in this patient should be:

A

Pancuronium

B

Atracurium

C

Rocuronium

D

Vecuronium

Ans.

B

Explanation:

B i.e. Atracurium

You might be thinking that this Q has never been asked, but think a while and try to understand that around which concept the Q is based. In other words, they are trying to ask that which muscle relaxant will not require reversal? I think now you need no explanation

– In pancuronium reversal is often required d/ t its longer duration of action

– In atracurium & cis-atracurium reversal is mostly not required due to its unique feature of spontaneous non eyzmatic degradation (Hoffmann elimination) Q.

Q. 16

A 30 year old woman with coarctation of aorta is admitted to the labour room for elective caesarean section. Which of the following is the anaesthesia technique of choice:

A

Spinal anaesthesia

B

Epidural anaesthesia

C

General anaesthesia

D

Local anaesthesia with nerve block

Q. 16

A 30 year old woman with coarctation of aorta is admitted to the labour room for elective caesarean section. Which of the following is the anaesthesia technique of choice:

A

Spinal anaesthesia

B

Epidural anaesthesia

C

General anaesthesia

D

Local anaesthesia with nerve block

Ans.

C

Explanation:

C i.e. General anesthesia

In coarctation of aorta any decrease in cardiac output or cardiac return is deleterious to the fetus because the placental circulation is already comprised on account of coarctation. So any anesthetic procedure/drug which causes hypotension should be avoided.

Regional anaesthic procedure such as spinal anesthesia and epidural anesthesia should be avoidedQ in these patients because hypotension is the most common side effect of these procedure.

General anesthesia is technique of choiceQ for performing cesarian section in a patient with coarctation of aorta, as it has advantage of – rapid induction, better airway & ventilation and less hypotension.

Q. 17

A multigravida woman was posted for emergency caesarean section. Correct statements are all of the following except-

September 2006

A

Cricoid pressure is applied while intubating

B

Isoflurane should not be used as it causes placental insufficiency

C

CS is done to prevent fetal distress and meconiumm aspiration

D

Cord clamping to be done after a few minutes

Q. 17

A multigravida woman was posted for emergency caesarean section. Correct statements are all of the following except-

September 2006

A

Cricoid pressure is applied while intubating

B

Isoflurane should not be used as it causes placental insufficiency

C

CS is done to prevent fetal distress and meconiumm aspiration

D

Cord clamping to be done after a few minutes

Ans.

B

Explanation:

Ans. B: Isoflurane should not be used as it causes placental insufficiency

General anaesthesia for CS:

It is given for fetal distress/if there is contraindication for spinal anaesthesia.

An initial assessment to determine the status of the mother and fetus is required.

It is now considered safe to treat placenta praevia on an outpatient basis if the fetus is at less than 30 weeks of gestation, and neither the mother nor the fetus are in distress.

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary.

In cases of fetal distress, associated complicating factors like malpresentation, elderly primigravidae, pregnancy with a previous caesarean section and contracted pelvis, a caesarean section is indicated.

Caesarean section is contraindicated in cases of disseminated intravascular coagulation.

Placenta praevia increases the risk of puerperal sepsis and postpartum haemorrhage because the lower segment to which the placenta was attached contracts less well post-delivery

Q. 20

Which of the following types of placenta complicates third stage of labour and is associated with a past history of caesarean section:

September 2011

A

Placenta succenturita

B

Placenta extracholis

C

Placenta membranecae

D

Placenat accrete

Q. 20

Which of the following types of placenta complicates third stage of labour and is associated with a past history of caesarean section:

September 2011

A

Placenta succenturita

B

Placenta extracholis

C

Placenta membranecae

D

Placenat accrete

Ans.

D

Explanation:

Ans. D: Placenta accreta

Most important risk factors for placenta accreta are the placenta praevia and prior caesarean delivery It complicates 3rd stage of labour (haemorrhage, shock, infection and rarely inversion of the uterus) Other types of placenta:

Biscoidal placenta: Placenta have 2 discs

Lobed placenta: Placenta divided into lobes

Placenta succenturita: Small part of placenta separated from the rest

Febestrated: Placenta having a hole in centre

Circumvallate: Edge of placenta is covered by circular fold of decidualis